Nokea
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
Correct Answer: B
Rationale: The correct answer is B because correctly identifying the client prior to a blood transfusion helps prevent a type II hypersensitivity reaction, which occurs when the body attacks its own cells due to mismatched blood types. This action ensures that the client receives compatible blood, reducing the risk of a transfusion reaction. Administering steroids for a positive TB test (A) is unrelated to preventing a type II hypersensitivity reaction. Keeping the client free of the offending agent (C) is more relevant to preventing a type IV hypersensitivity reaction. Providing a latex-free environment for the client (D) is important for preventing a type I hypersensitivity reaction in latex-sensitive individuals, not type II reactions related to blood transfusions.